1. High-risk related to physiologic factors
Respiratory distress syndrome

2. Respiratory distress syndrome RDS
Respiratory distress is a name applied to respiratory dysfunction in neonates and primarily a disease related to developmental delay in lung maturation.
Respiratory distress syndrome (RDS) and hyaline membrane disease) are often applied to sever lung disorders, which not only is responsible for more infants deaths than any other diseases , but also carries the highest risk in terms of long- term respiratory and neurologic complications

3. Respiratory distress syndrome RDS
It is seen almost exclusively in preterm infants.
Causes:
Pulmonary origin.
Nonpulmonary origin:
Sepsis.
Cardiac defects (structural or functional).

4. Causes of RDS Exposure to cold. Airway obstruction (atresia).
Intraventricular Hge.
Hypoglycemia.
Metabolic acidosis.
Acute blood loss
Drugs.

5. Pathophysiology Pulmonary origin
Preterm infants are born with numerous underdeveloped and many uninflatable alveoli.
Poor vascular development and an immature capillary network __limited pulmonary blood flow as a result of collapsed status of the fetal lungs __increased pulmonary vascular resistance__ the major portion of fetal blood is shunting from the lung by way of the ductus arteriosus and foramen ovale.

6. Pathophysiology After birth, infants must initiate breathing
And keep previously fluid- filled lungs
inflated with air
At the same time, the pulmonary capillary blood flow must be increased approximately tenfold to provide for adequate lung perfusion and to alter intra-cardiac pressure that closes the fetal

7. Pathophysiology Cardiac structures
Most full –term infants accomplish these adjustment, but pre-term infants with RDS are unable to do so.
Although numerous factors are involved, immaturity of the surfactant system plays a central role

8. Pathophysiology
Surfactant is a surface-active phospholipids secreted by the alveolar epithelium. Acting like a detergent. reduces the surface tension of fluid that line the alveoli and respiratory passages resulting in uniform expansion and maintain of lung expansion at low intra-alveolar pressure.

9. Surfactant

10. Pathophysiology
Deficient surfactant production causes unequal inflation of alveoli on inspiration and the collapse of alveoli on end expiration.
Without surfactant, infants are unable to keep their lungs inflated .

11. Pathophysiology
Therefore, exert a great deal of effort to re-expand the alveoli with each breath
With increasing exhaustion, infants are able to open fewer and fewer alveoli.
This inability to maintain lung expansion produces widespread atelectasis.

12. Pathophysiology
Atelectasis__ increase pulmonary vascular resistance (PVR) whereas with normal lung expansion it would decreased __hyoperfusion of the lung lissue with decrese in effective pulmonary blood flow----- partial reversion to the fetal circulation, with a right-to-left shunting of blood through ductus arteriosus and foramen ovale__ hypoxemia, hypercapnia__ activate anaerobic glycolysis produces increase amount of lactic acid__ metabolic acidosis.

13. hypercapnia __ respiratory acidosis__ decrease blood pH
hypercapnia __ respiratory acidosis__ decrease blood pH. acidosis causes further vasoconstriction.

15. ARDS

16. Diagnostic Evaluation
The diagnostic of RDS is made on the basic of clinical manifestations box 9-8p:273
Respiratory S & S:
Tachypnea b/min.
Dyspnea.
Pronounced intercostal and /or substernal retraction(FIG.9-16).
Fine inspiratory crackles.
Audible expiratory grunt.
Flaring of the external nares.
Cyanosis or pallor.

17. Diagnostic Evaluation
Manifestation as the disease prognoses:
Apnea flaccidity mottling.
Absent spontaneous movement.
Unresponsiveness.
Diminished breath sounds
Manifestation associated with sever disease:
Shock like state.
Decreased cardiac output and bradycardia.
Low systemic blood pressure.

18. Diagnostic Evaluation
Radiographic studies:
A diffuse granular pattern over both lung fields represent alveolar atelectasis.
Dark streaks represent dilated ,air filled bronchioles
Respiratory function: blood gas analysis.
Criteria for visually evaluating the degree of respiratory distress: Fig

19. Upper chest grade 0:synchronized

20. Upper chest : log in inspiration grade 1

21. Grade 2 :Upper chest : see-saw

22. Lower chest: no retraction: grade 0

23. Lower chest: : just visible retraction : grade 1

24. Lower chest: :marked retraction grade 2

25. Xiphoid retractions grade 0: none

26. grade 1 Xiphoid retractions : just visible

27. Xiphoid retractions : marked grade2:

28. Grade 0:no nares dilation and expiration grunt

29. Grade 1:nares minimal dilation and expiration stethoscope only grunt

30. Grade 2:nares marked dilation and expiration naked ear grunt

31. Therapeutic management
The treatment of RDS involves immediate establishment of adequate
1. oxygenation
2. ventilation . Then:
3. The supportive care: to a favorable outcome are:
Maintain adequate ventilation and oxygenation.
Maintain acid-base balance.
Maintain a neutral thermal environment.
Maintain adequate tissue perfusion and oxygenation.

32. Therapeutic management
Prevent hypotension.
Maintain adequate hydration and electrolyte status.
Nipple and gavages feeding are contraindicated in any situation that increase hazard of aspiration, and necrotizing enterocolitis.
Nutrition is provided by Parenteral therapy during the acute stage of the disease.
The administration of exogenous surfactant.
It is derived from a natural source (e.g. porcine, bovine) or from the production of artificial surfactant.

33. Therapeutic management
It is administered via an endotracheal (ET) tube directly into infant's trachea.
Nursing responsibilities with surfactant administration include:
Assistance in the delivery of the product.
Collection and monitoring of ABGs .
Monitor oxygenation with pulse oximetry.
Suctioning is usually delayed for
an hour to allow maximum
effects to occur.

34. Therapeutic management
Complications seen with surfactant administration include: Pulmonary Hge, and mucous plugging.
Prevention : by preventing premature delivery.
Prognosis:
In the absent of complication, affected infants begin to improve by 72 hours
Complication of RDS include associated respiratory conditions and problems associated with prematurity: patent ductus arteriosus, CHF, intraventricular He, sepsis, bronchopulmonary dysplasia, retinopathy…

35. Nursing consideration
Assessment:
- The most essential nursing function is to observe and assess the infants response to therapy.
Continuous monitoring and close observation are mandatory because:
an infant's status can change rapidly
oxygen concentration and ventilation parameters are prescribed according to the infant's blood gas measurements and pulse oximetry readings.

36. Nursing consideration
Nursing diagnoses: high-risk infant
Ineffective breathing pattern related to surfactant deficiency, alveolar instability, and pulmonary immaturity.
Ineffective breathing pattern related to decreased energy.
Impaired gas exchange related to immature alveolar structure .
impaired gas exchange related to inability to maintain lung expansion.
Risk for trauma (brain tissue) related to hypoxemia and hypercapnia.

37. Nursing consideration
Planning: high-risk infant
Infant will exhibit optimum air exchange and oxygenation.
Infant will exhibit desired respiratory, cardiac, thermoregulatory, Neurologic, and metabolic function.

38. Nursing consideration
Implementation:
Suctioning should be performed only when necessary and should be based on individual infant assessment, which include:
Auscultation of the chest,
Evidence of decreased oxygenation.
Excess moisture in the ET tube.
Increase infant irritability
Suction applied beyond the ET tube can cause traumatic lesions of the trachea.
Some recommend that the Fio2 be increased by 10% before suctioning to compensate for a decrease in Fio2 during the procedure
The use of in-line suction catheters or closed suctioning system may decrease air way contamination and hypoxia.

39. Nursing consideration Implementation
Positions:
the most advantageous positions for facilitating an infant's open airway are on the side with the head supported in alignment by a small folded blanket .
On the back, to keep the neck slightly extended.
With the head in the “sniffing” position the trachea is opened at its maximum,
Hyperextension reduces the tracheal diameter in neonates.
Inspection of the skin:
Position changes and the use of water pillows are helpful in guarding against skin breakdown.
Mouth care:
drying and cracking can be prevented by good oral hygiene using sterile water
Irritation on the nares or mouth may be reduced by the use of a water-soluble ointment.